Provider Demographics
NPI:1598412488
Name:POLSON, BONNIE J (MA)
Entity Type:Individual
Prefix:MS
First Name:BONNIE
Middle Name:J
Last Name:POLSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1591 CARPENTIER ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4470
Mailing Address - Country:US
Mailing Address - Phone:559-307-5606
Mailing Address - Fax:
Practice Address - Street 1:1591 CARPENTIER ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4470
Practice Address - Country:US
Practice Address - Phone:559-307-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-09
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP3913235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty